Slide 17:

Vagal innervation of the stomach. The line of division for truncal vagotomy is shown and is above the hepatic and celiac branches of the left and right vagus nerves, respectively. The line of division for selective vagotomy is shown and occurs below the hepatic and celiac branches.

Slide 18:

Dotted line represents the line of dissection for parietal cell or highly selective vagotomy. Note that the last major branches of the nerve are left intact and that the dissection begins 7 cm from the pylorus. At the gastroesophageal junction, the dissection is well away from the origin of the hepatic branches of the left vagus

Slide 25:

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Slide 29:

Mobilization of the splenic flexure and release of omentum from the transverse colon

Slide 30:

Site of resection of the stomach

Slide 31:

Hemostatic sutures

Slide 32:

Gastric opening should be approximately 2.5 to 3 cm wide
Direct end-to-end anastomosis with the duodenum

Slide 33:

Anastomosis

Slide 34:

Vascular pedicles on the gastric side are anchored to the ligated right gastric pedicle along the top surface of the duodenum

Slide 35:

BILLROTH –I Modifications

Slide 37:

BILLROTH II HEMIGASTRECTOMY
(POLYA)

Slide 38:

The antrum is resected as in a Billroth I operation. The distal portion of the resection line is excised

Slide 39:

The jejunal segment, located 10 to 20 cm beyond the ligament of Treitz, is brought through a window in the retrocolic mesentery

Slide 40:

The gastrojejunal anastomosis is constructed in two layers

Slide 41:

Retrocolic window in the mesentery is closed in order to avoid herniation of other viscera. The mesentery is linked to gastric wall, positioning the anastomosis below the closure

Slide 42:

BILLROTH-II Modifications

Slide 44:

BILLROTH-II Roux-en-Y modification

Slide 45:

Polya modification

Slide 46:

SUBTOTAL GASTRECTOMY

Slide 48:

Extent and fixation of the tumor mass by exploring the lesser omental cavity through an opening made in the relatively avascular gastrohepatic ligament

Slide 49:

Kocherization of duodenum

Slide 50:

CBD is identified & preserved

Slide 51:

Gauze tape is brought up through an avascular space along the greater curvature and is used for traction

Slide 52:

Gastrocolic ligament is ligated close to the greater curvature

Slide 54:

Sacrifice of the left gastroepiploic artery and one or two of the short gastric arteries in the gastrosplenic ligament. The nutrition of the remaining fundus of the stomach depends upon the remaining short gastric arteries

Slide 55:

Cutting the splenocolic ligament for mobilizing the greater curvature

Slide 56:

right gastroepiploic vessels should be carefully isolated from the surrounding fat and securely ligated over the duodenum

Slide 57:

Most medial portion of the hepatoduodenal ligament, which includes the right gastric artery, is divided

Slide 58:

Transfixing silk traction sutures are applied to the superior and inferior borders of the duodenum adjacent to its retained blood supply. Pylorus is freed

Slide 59:

Clamps applied

Slide 60:

Ligation of the small vascular attachments between duodenum and pancreas must be carried out without damaging the gastroduodenal artery

Slide 61:

Duodenal clamps removed

Slide 62:

Duodenal stump closed in 2layers

Slide 63:

Anterior wall of duodenum to capsule of pancreas

Slide 64:

Gastrohepatic ligament dissection

Slide 65:

If not radical – Left gastric gastric vessels maintained

Slide 69:

Left gastric artery as far away from the lesser curvature as possible

Slide 71:

Clamped applied over the stomach

Slide 72:

TOTAL GASTRECTOMY

Slide 74:

At least 2.5 to 3 cm of duodenum distal to the pyloric veins should be resected

Slide 75:

Palpation of posterior aspect of stomach

Slide 76:

Free mobility of the growth without involvement of fixation to the underlying pancreas or major vessels, especially in the region of the left gastric vessels

Slide 77:

The right gastroepiploic vessels are doubly ligated as far away from the interior surface of the duodenum as possible, to ensure removal of the infrapyloric lymph nodes and adjacent fat

Slide 78:

Right gastric vessels along the superior margin of the first part of the duodenum are isolated by blunt dissection and doubly ligated some distance from the duodenal wall

Slide 79:

Duodenum is divided

Slide 80:

Duodenum should be freed from the adjacent pancreas, especially inferiorly, where a few vessels may enter the wall of the duodenum

Slide 81:

Slide 82:

Uppermost portion of the gastrohepatic ligament, which includes a branch of the inferior phrenic vessel, is isolated by blunt dissection

Slide 83:

Left gastric vessels are isolated from adjacent tissues

Slide 84:

Wall of the esophagus can be lightly anchored to the crus of the diaphragm on both sides, as well as anteriorly and posteriorly and also to approximate the crus of the diaphragm

Slide 85:

Prevent fraying of the muscle layers by fixing the mucosa to the muscle coats proximal to the point of division

Slide 87:

Oesophagus is then divided between this suture line and the gastric wall

Slide 88:

Arcades of blood vessels of jejunum defined

Slide 89:

Two or more arcades of blood vessels are divided and a short segment of devascularized intestine resected if needed

Slide 90:

If E-S anastamosis ,then end of jejunum is closed

Slide 91:

Opening of Mesocolon

Slide 92:

Row of interrupted 00 silk sutures is placed to approximate the jejunum to the diaphragm on either side of the esophagus

Slide 94:

Jejunum opened

Slide 95:

Layer of interrupted silk sutures is used to close the mucosal layer, starting at either end of the jejunal incision with angle sutures

Slide 96:

Interrupted Connell-type sutures closing the anterior mucosal layer
Jejunum is anchored to the diaphragm, the wall of the esophagus, and the mucosa of the esophagus, a three-layered closure is provided

Slide 97:

Peritoneum, which has been initially incised to divide the vagus nerve and mobilize the esophagus, is brought down to cover the anastomosis and anchored with interrupted silk sutures to the jejunum

Slide 98:

Mesentery is anchored to the posterior parietal wall

Slide 99:

Open end of the proximal jejunum anastomosed at an appropriate point in the jejunum) with two layers and the opening into the mesentery beneath the anastomosis is closed with interrupted sutures to prevent herniation